Demonstrates expertise in conducting complex investigations within the healthcare sector, including knowledge of Medicare and Medicaid regulations. Proficient in analyzing evidentiary patterns, preparing detailed reports, and effectively communicating findings to various stakeholders.

Highest-signal resume keywords

Investigative SkillsKnowledge Of Medicare And Medicaid ProgramsHealthcare Industry ExperienceStrong Communication SkillsAbility To Analyze Medical Claims

About the role

Key responsibilities & impact

Perform high-level, complex investigations of medical professional service providers
Develop cases for law-enforcement referral, education, overpayment recovery, and other administrative actions
Work with internal resources, external agencies, state investigators, and federal investigators to develop cases and corrective actions
Respond to requests for data and support
Manage multiple caseload assignments concurrently
Organize and analyze complex evidentiary patterns
Interview witnesses and other individuals and obtain statements
Complete complex investigative reports applying regulations, rules, and federal or state laws
Research relevant offenses and conduct efficient investigations to detect or verify suspected violations
Obtain information and evidence through observation, record examination, and interviews
Analyze investigative results to determine whether allegations are corroborated and recommend appropriate actions
Prepare objective and accurate correspondence
Maintain confidentiality of health privacy information and comply with applicable laws, rules, and regulations
Adapt investigative activities to unplanned situations and changing circumstances
Educate providers and other stakeholders on program safeguard matters
Attend meetings, training, and conferences; testify in court when required

Requirements

What you’ll need

2 years with BS/BA; 6 years with a HS diploma/equivalent
Knowledge of Medicare and/or Medicaid programs and related rules, regulations, policies and procedures
Knowledge and experience in the healthcare industry
Strong investigative skills
Strong communication and organization skills
Strong PC knowledge and skills
US citizenship is required
Experience reviewing claims for technical requirements, performing medical review, and/or developing fraud cases preferred
Knowledge of investigative practices regarding healthcare providers preferred
Background evaluating, reviewing, and analyzing medical claims and records preferred
Ability to learn and operate data systems, equipment, and tools used in investigations
Ability to research and draw conclusions
Ability to organize case files and accurately document investigative steps
Ability to cite regulatory violations and allege schemes or scams to defraud the Government
Ability to compose correspondence, reports, and referral summary letters
Ability to communicate effectively internally and externally
Ability to interpret laws and regulations
Ability to handle confidential material
Ability to manage and prioritize workload effectively
Ability to educate providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups
Ability to work independently and as a member of a team
Ability to attend meetings, training, and conferences; overnight travel required
May be required to appear in court and testify about work findings

Benefits

Comp & perks

Telework available from specified U.S. locations
Overtime eligibility may apply
Shift differential may apply
Discretionary bonus may apply

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Investigative ReportingData AnalysisRegulatory InterpretationMedical ReviewClaims ReviewEvidence CollectionCase ManagementFraud DetectionRecord ExaminationPattern Analysis

Soft Skills

Strong Organizational SkillsEffective CommunicationAdaptabilityTeam CollaborationConfidentiality Management

Tools & Technologies

Data SystemsInvestigation Equipment

Industry Keywords

Healthcare RegulationsFraud InvestigationOverpayment RecoveryAdministrative ActionsWitness InterviewingEvidentiary PatternsComplianceConfidential Health InformationStakeholder EducationCourt Testimony